J. Acad. Indus. Res. Vol.

1(12) May 2013 778

ISSN: 2278-5213

REVIEW ARTICLE

Surgical Sutures: An overview

K.P. Chellamani*, D. Veerasubramanian and R.S. Vignesh Balaji
The South India Textile Research Association (SITRA), Coimbatore-641014, TN, India
kpc@sitra.org.in*; 0422-4215347
______________________________________________________________________________________________
Abstract
Sutures are used to close the cuts caused by injuries or to close the incision due to surgery and
other medical procedures like wound approximation. They are commonly used on the skin, internal tissues,
organs and blood vessels. They are available in the form of monofilament, multifilament/braided and pseudo
monofilament. A lubricant is applied on the surface of braided suture material to lower the tissue drag and
allow better knotability. They are also available in the form of either absorbable or non-absorbable sutures.
Absorbable sutures undergo degradation and loss of tensile strength within 60 d whereas, the
non-absorbable sutures retain tensile strength for longer than 60 d. The most important characteristics in
biodegradation and absorption of absorbable sutures are the strength and mass loss profiles and the
biocompatibility of degradation materials. Synthetic absorbable sutures can be degraded by a hydrolytic
mechanism via the scission of ester linkages in the polymeric backbone. This review focuses on suture and
their classification in terms of suture manufacturing process. Further it is classified based on sutures
absorption ability and the origin of raw material.
Keywords: Sutures, incision, monofilament, multifilament, pseudo monofilament, hydrolytic process.

Introduction
Sutures have been used for at least 4000 years.
Archeological records from ancient Egypt showed that
Egyptians used linen and animal sinew to close wounds
(Abdessalem et al., 2009). Sutures are the most
frequently used biomaterial for wound closure and tissue
approximation (Chellamani and Veerasubramanian,
2010). They are used to close the cuts caused by injuries
or to close the incision due to surgery and other medical
procedures like wound approximation. They are
commonly used on the skin, internal tissues, organs and
blood vessels. There are two different kinds of sutures.
One is absorbable sutures that will dissolve on their own.
Another one is non-absorbable sutures that will be
removed after certain period of time (Raul De Persia
et al., 2005). The suture market currently exceeds $1.3
billion annually. US Pharmacopoeia (USP), European
Pharmacopoeia (EP) and British Pharmacopoeia (BP)
are the official compendium for the suture industry, which
sets standards and guidelines for suture manufacture.
Suture sizes are given by a number representing
diameter ranging in descending order from 10 to 1 and
then 1O to 12O, 10 being the largest and 12O being
the smallest at a diameter than a human hair (Anand,
2006).
Monofilament
A monofilament with its smooth surface can only be
made from synthetic material by polymer extrusion
method. The important property of the monofilament is a
minimal tissue reaction. This is because of monofilament
smooth surface. Also the monofilament suture does not
allow any bacteria to survive as compared to
multifilament sutures. It is also easy to make or place a
knot in the depth of the body. The main drawbacks of the
monofilament are low knot security and less flexibility.
Polyester, polyamide, polypropylene and polydioxanone
are used as monofilament suture. Polyester has a high
knot-pull tensile strength, good flexibility and low
degradation. Polypropylene has excellent tissue drag
and stability. Polydioxanone and polyglycolic
acid-polycarbonate copolymer are dissolved gradually in
body tissue by means of hydrolytic process. The violet
dyed monofilament suture is shown in Fig. 2.
Fig. 2. Violet dyed monofilament suture
(Chellamani et al., 2012).

Classification of suture
Sutures can be broadly classified in to 3 groups based
on their manufacturing process. They are i) Monofilament
sutures, ii) Multifilament sutures and iii) pseudo
monofilament sutures (Sabit Adanur, 1995; Sathish
Bhalerao et al., 1998; Desai, 2005; Stashak and Theoret,
2008). The broad classification of the sutures is shown in
Fig. 1.

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J. Acad. Indus. Res. Vol. 1(12) May 2013 779

Fig. 1. Classification of surgical suture thread based on their manufacturing process.

Multifilament/Braided suture
Multifilament yarns can be twisted together to form a Fig. 4. Pseudo-monofilament (Chellamani et al., 2012).
braided sutures. To form a braided suture, in general,
eight to sixteen monofilament yarns are to be used.
Obviously, due to the manufacturing method, the braided
sutures have rough surface which causes tissue drag to
be high. A lubricant is applied on the surface of braided
suture material to lower the tissue drag and allow better
knotability. Braids are also flexible and easy to handle as
compared to monofilament sutures. Polyesters,
polyamides and silks are commonly used for
manufacturing braided sutures. The suture in the form of
a braid is shown in Fig. 3.

Fig. 3. Braided suture (Chellamani et al., 2012). It has low tissue drag, good knotability and fair flexibility.
It has drawbacks like low knot security as like mono
filament sutures. The structure of pseudo-monofilament
is shown in Fig. 4.

Absorbable and non-absorbable sutures

Surgical sutures can be further classified in two groups.
They are i) absorbable suture and ii) non-absorbable
suture.

Absorbable sutures: Absorbable sutures undergo

Pseudo-monofilament
The pseudo-monofilament has a core of several twisted
materials coated with an extrusion of the same material
as the core.
degradation and loss of tensile strength within 60 d,
either by enzymal degradation and subsequent hydrolytic
or by hydrolytic alone (eg.: polyglycolic acid (Dexon)).
The absorbable suture can be further classified in two
groups. They are i) Natural and ii) Synthetic.

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J. Acad. Indus. Res. Vol. 1(12) May 2013
Natural
Catgut: Catgut the widely used suture is derived from
animal intestines and is over 99% pure collagen.
It is made from the submucosa of sheep intestines or the
serosa of beef cattle intestines. It is monofilament and is
absorbed by a process of enzymatic digestion.
Absorption rate depends on size and also on whether the
gut is plain or chromicised. The great advantage of
catgut is that being absorbable it can be used even in the
presence of infection. Tensile strength loss is faster than
absorption.
Collagen: It was evolved to overcome the disadvantages
of conventional catgut. The flexor tendons of beefs were
converted into dispersed fibrils. The dispersed fibrils
were then extruded and reconstituted to form collagen
sutures.
Synthetic
Dexon, vicryl and PDS are the available synthetic
absorbable suture.
Polydioxanone: It is in monofilament form and it is
derived from the polymer of Polydioxanone.
It is absorbed by hydrolysis in 180 to 190 d. It losses
26% of tensile strength after 14 d of implantation,
42% after 28 d and 86% after 56 d of implantation.
After 6 weeks of implantation this suture still has half-life
of tensile strength. It has good knot security, minimal
tissue drag and minimal foreign body reaction. The main
drawback of this suture is poor handling characteristics
due to its stiffness and memory.
Polyglyconate: It is the copolymer of glycolic acid and
trimethylene. It is in monofilament nature. It is absorbed
by hydrolysis starting at day 60 and complete by day
180. It retains the tensile strength for more than 21 d.
The half- life of the breaking strength is around 28 d.
It has good handling characteristics, best knot security of
all synthetic monofilament absorbable sutures.
It is superior to nylon and polybutester for tendon repair.
Poliglecarprone: It is in monofilament form and it is the
copolymer of caprolactone and glycolide. It is absorbed
by hydrolysis in 90 to 120 d. It losses 50% of tensile
strength at 7th d of implantation, 75% of tensile strength
at 14th d and 100% of tensile strength at 21th d of
implantation. It has excellent knot security, minimal
tissue reaction and good handling characteristics due to
its decreased flexibility and minimal memory.
Due to rapid loss of tensile strength after implantation, it
should be used for tissues that heal rapidly.
Polyglycolic acid: It is the braided structure sutures.
It is synthesized from glycolic acid. It is absorbed by
hydrolysis in 100 to 120 d. It loses its tensile strength by
33% within 7 d of implantation and by 80% within 14 d of
implantation.
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It is widely used in clean and contaminated wounds.
It has superior tensile strength as compared to catgut
sutures and it has good suture handling characteristics.
It has drawbacks like poor knot security and poor stability
in alkaline environment.
Polyglactin 910: It is available in braided form. It is the
copolymer of glycolic acid and lactic acid and it is coated
with calcium stearate. It is absorbed by hydrolysis over a
period of 100 to 120 d. It retains tensile strength for first
14 to 21 d of implantation. It is also available in coated
form. The coated form polyglacting 910 suture is easier
to handle and it has less tissue drag, minimal tissue
reaction and stable in contaminated wounds. It has
advantages like stable in alkaline environment, higher
tensile strength and knot strength.
Non-absorbable sutures
Non-absorbable sutures retain tensile strength for longer
than 60 d (eg.: Polypropylene (Prolene)). As like
absorbable sutures, the non-absorbable sutures are also
classified in two groups. They are i) Nature and ii)
Synthetic.
Natural
Silk: It is available in braided form. It is made of cocoon
of silk worm larvae. Sometimes it is coated with oil, wax
or silicone. It loses its strength after two years.
It has excellent handling characteristics and knot
security. It is mostly used in ophthalmology (Chatterjee,
1975). The main drawbacks of this sutures are coating
reduced the knot security, incites tissue reaction,
infection and capillarity.
Linen: It is made from flax. It is available in twisted form.
It can be used for general surgery, gynecology,
cardiovascular surgery, gastrointestinal surgery and
plastic surgery. The Linen suture is not absorbed and
hence it does not loss the tensile strength (Shalon
Suturas, 2013). It gains 10% of tensile strength when it is
wet. It is also available in treated with silicone and
polyvinyl solution (B braun sutures Linatrix, 2013).
It has better handling characteristics and excellent knot
security.
Cotton: It was introduced as a suture material in 1939 to
replace silk suture during World War II. It is extracted
from hairs of seed of cotton plant. It gains tensile
strength and knot security when wet. It slowly losses
tensile strength after implantation, with 50% loss of
tensile strength at 6 months, and 70% loss of tensile
strength at 2 years. However it is not absorbable sutures.
It has better knot security than silk. Disadvantages of
cotton suture are its capillarity, tissue reactivity, inferior
handling ability due to electrostatic properties and ability
to potentiate infection (Boothe, 1993).
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J. Acad. Indus. Res. Vol. 1(12) May 2013
Synthetic
Polyester: Polyester suture is a braided multifilament
available in plain and coated forms. Coatings, which
include polybutylate, Teflon, and Silicone which decrease
drag when the suture is drawn through tissue.
This suture is one of the strongest nonmetallic sutures
available and undergoes little or no loss in tensile
strength after implantation in tissues. Once properly
placed, polyester sutures offer prolonged support for
slowly healing tissues. The main disadvantages of
polyester suture are its poor knot security, high
coefficient of friction and tissue reactivity particularly in
contaminated environments.
Polyamide: Nylon and polymerized caprolactum are
examples of readily available polyamide sutures.
It is available as both monofilament and multifilament
form. After implantation, monofilament nylon sutures
losses about 30% of its original tensile strength by
2 years because of chemical degradation. Multifilament
nylon loses essentially 100% of its tensile strength after
6 months in tissue. The main drawbacks of polyamide
suture are its poor handling characteristics and knot
security.
Polypropylene: It is available in monofilament form.
It is synthesized from polyolefin plastics. It retains tensile
strength without reduction after implantation. It has
higher knot security than all monofilament non-metallic
synthetics suture materials. It is the best suture for skin
closure. However, the tensile strength is less as
compared to all monofilament nonmetallic sutures.
Polybutester: It is the monofilament form of suture.
It is the copolymer of polybutylene, polyglycol and
polytetramethylene terephtalates. It retains its breaking
strength after implantation. It has good handling
characteristics and knot security. It provides prolonged
support for slow healing tissues. The main drawback of
this suture is marginal knot quality, that is, if the force is
applied to this suture, it causes fibers to interlock.
Stainless steel: Stainless steel is the only metallic suture
still widely used. It is available in both monofilament and
braided form. It is biologically inert and non-capiallary in
nature. It can be easily sterilized by autoclaving process.
It has the highest tensile strength and greatest knot
security of all suture materials and maintains this
strength on implantation in tissues. It is good for suturing
tissues that heal slowly. The monofilament form stainless
sutures are used effectively in contaminated and infected
wounds, because it does not support infection.
Disadvantages of stainless steel suture are its tendency
to cut tissues, poor handling characteristics (especially in
knot tying) and diminished ability to withstand repeated
bending without breaking.
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Absorption behavior of suture materials
After implanting the absorbable suture in tissue, the
suture materials are broken down by enzymal and
hydrolytic process. Table 1 is an illustration of structural
factors of polymers that could control their degradation
(Bronzino, 2000). The most important characteristics in
biodegradation and absorption of sutures are the
strength and mass loss profiles and the biocompatibility
of degradation materials. Although there is a wide range
of strength and mass loss profiles among the available
absorbable sutures. They have one common
characteristic: Strength loss always occurs much earlier
than mass loss. The vast amounts of published
information are available about the biodegradation
phenomena of synthetic absorbable sutures. It shows
that these synthetic absorbable sutures can be degraded
by a hydrolytic mechanism via the scission of ester
linkages in the polymeric backbone. The observed wide
range of strength and mass loss profiles of absorbable
sutures is attributable not only to the chemical
differences among the absorbable sutures but also to a
variety of intrinsic and extrinsic factors, such as pH,
electrolytes, stress applied, temperature, irradiation,
microorganisms and tissue type. A study of the effect of
superoxide ion on the degradation of absorbable sutures
has been reported. Superoxide ion can act as an oxygen
nucleophile agent to attack the ester linkage in
absorbable suture polymers and it induces hydrolytic
degradation (Dumitriu, 2002).
Table 1. Structural factors to control the polymer
(absorbable sutures) degradability.
Factors Methods of control
Chemical structure of main Selection of chemical bonds
chain and side groups and functional groups
Processing,
Aggregation state
copolymerization
Crystalline state Polymer blend
Copolymerization,
Hydrophilic/hydrophobic
introduction of functional
balance
groups
Surface area Micropores
Shape and morphology Fiber, film and composite
Conclusion
Sutures are used to close the cuts caused by injuries or
to close the incision due to surgery and other medical
procedures like wound approximation. They are
commonly used on the skin, internal tissues, organs and
blood vessels. Compared to monofilament sutures,
multifilament sutures have good handling properties as
well as knot security. However, the multifilament sutures
have the property of capillarity which helps to capillary
the wound fluid. Hence, it causes to spread infection
throughout the wound site.
Chellamani et al., 2013
J. Acad. Indus. Res. Vol. 1(12) May 2013
Due to the advanced polymer science research,
compared to non-absorbable sutures, the available
absorbable sutures leads less tissue reaction after
implantation and during absorption process.
Acknowledgements
Authors are thankful to Dr. Prakash Vasudevan, Director,
SITRA for his keen interest in this study.
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